Saturday, July 27, 2013

Five-day steroid course effective for acute COPD exacerbations

For inpatients with acute exacerbations of chronic obstructive pulmonary disease (COPD), five days of glucocorticoids is as effective as 14 days at preventing re-exacerbations at six months, a study found.
Researchers studied 314 Swiss patients who presented to the emergency department with acute COPD exacerbation between March 2006 and February 2011. Patients received treatment with 40 mg of prednisone daily for either 5 or 14 days in a placebo-controlled manner. In addition to prednisone, all patients received a broad-spectrum antibiotic for seven days and an inhaled, nebulized, short-acting bronchodilator four to six times daily as needed while in the hospital. Additional glucocorticoids could be given at the physician's discretion. The main outcome was time to the next exacerbation, within 180 days. Results were published online May 21 by the Journal of the American Medical Association.
Ninety-two percent (n=289) of randomized patients were admitted to the hospital; 311 were included in the intention-to-treat analysis and 296 in the per-protocol analysis. Estimates of re-exacerbation rates were 37.2% in the short-term treatment group and 38.4% in the longer-term (conventional) treatment group. Time to re-exacerbation did not differ between the groups. There was no difference between groups in time to death, the combined end point of exacerbation, death, or both and recovery of lung function. In the conventional group, the mean cumulative prednisone dose was significantly higher (793 mg vs. 379 mg; P<0.001), but treatment-associated adverse reactions, including hyperglycemia and hypertension, occurred with equal frequency. There was a non-significant trend toward fewer instances of hypertension in the short-term group. There also was no difference between groups in the requirement for mechanical ventilation while hospitalized.
The findings support the use of a five-day course of glucocorticoid treatment in acute exacerbations of COPD, rather than the current guidelines for a 10- to 14-day course, the researchers and editorialists concluded. About 10% of patients experience two or more exacerbations yearly, and cumulative exposure to corticosteroids can be substantial and lead to long-term toxicity, including weight gain, diabetes, osteoporosis and fractures. As such, it is important to use the minimal effective dose, the editorialists wrote.

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